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      Severe ischaemic cardiogenic shock with cardiac arrest and prolonged asystole: a case report

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          Abstract

          Background

          Extracorporeal life support (ECLS) by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a valuable treatment option during severe cardiogenic shock and during cardiac arrest unresponsive to conventional management. It is applied to bridge the first critical days until the patient recovers or a destination therapy is established. 1 Prolonged episodes without cardiac electrical activity during VA-ECMO are a major problem, as they may cause pulmonary oedema and severe left ventricular (LV) thrombosis. 2 Here, we report a case of a 50-year-old man who presented with a 30-h episode of complete absence of electromechanical activity during ECLS and finally recovered with favourable neurological outcome.

          Case summary

          A 50-year-old man with out-of-hospital cardiac arrest was transferred to a peripheral hospital after initial successful cardiopulmonary resuscitation (CPR). In the emergency room, he presented with ST-segment elevation myocardial infarction and cardiogenic shock with third-degree atrioventricular block. After immediate insertion of a temporary pacemaker, he received percutaneous coronary intervention of the left anterior descending artery and the circumflex artery. Due to worsening cardiogenic shock, ECLS with VA-ECMO and an Impella ® pump was established. Cumulative time of CPR (out of hospital and in hospital) was 41 min. After transfer to our institution’s intensive care unit, both the heart’s mechanical and electrical activity ceased for more than 24 h and recovered slowly thereafter. After showing promising neurological outcome, epicardial pacemaker leads, an implantable cardioverter-defibrillator, and finally, a LV assist device were implanted. He was dismissed into rehabilitation with only minor neurological residua 6 weeks later.

          Discussion

          Impella ® implantation on top of VA-ECMO may be considered beneficial in the therapy of prolonged cardiac arrest. 3 While VA-ECMO ensures oxygenation and organ perfusion, Impella ® vents the left ventricle and enhances coronary perfusion. In the presented case, a favourable outcome was reached despite an ‘untreated’ prolonged absence of cardiac electromechanical activity. Under specific circumstances during ECLS with extracorporeal membrane oxygenation and Impella ®, waiving of temporary pacing may be considered in absent cardiac electromechanical activity to avoid further complications.

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          Most cited references11

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          Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

          Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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            Clinical picture and risk prediction of short-term mortality in cardiogenic shock.

            The aim of this study was to investigate the clinical picture and outcome of cardiogenic shock and to develop a risk prediction score for short-term mortality.
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              Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective.

              Limited information is available about potentially changing and contemporary trends in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction. The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the incidence rates of cardiogenic shock complicating acute myocardial infarction, patient characteristics and treatment practices associated with this clinical complication, and hospital death rates in residents of a large central New England community hospitalized with acute myocardial infarction at all area medical centers. The study population consisted of 13 663 residents of the Worcester (Mass) metropolitan area hospitalized with acute myocardial infarction at all greater Worcester medical centers during 15 annual periods between 1975 and 2005. Overall, 6.6% of patients developed cardiogenic shock during their index hospitalization. The incidence rates of cardiogenic shock remained stable between 1975 and the late 1990s but declined in an inconsistent manner thereafter. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (65.4%) than those who did not develop cardiogenic shock (10.6%) (P<0.001). Encouraging increases in hospital survival in patients with cardiogenic shock, however, were observed from the mid-1990s to our most recent study years. Several patient demographic and clinical characteristics were associated with an increased risk for developing cardiogenic shock. Our findings indicate improving trends in the hospital prognosis associated with cardiogenic shock. Given the high death rates associated with this clinical complication, monitoring future trends in the incidence and death rates and the factors associated with an increased risk for developing cardiogenic shock remains warranted.
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                Author and article information

                Journal
                Eur Heart J Case Rep
                Eur Heart J Case Rep
                ehjcr
                European Heart Journal: Case Reports
                Oxford University Press
                2514-2119
                September 2018
                27 July 2018
                27 July 2018
                : 2
                : 3
                : yty088
                Affiliations
                [1 ]Department of Cardiology, University Heart Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
                [2 ]Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg, Germany
                Author notes
                Corresponding author. Tel: +49 (0) 40 7410 - 53972, Fax: +49 (0) 40 7410 - 53622, Email: f.strangl@ 123456uke.de . This case report was reviewed by Albert Galyavich, Ola Jan Magnus Vedin, and Mark Philip Cassar.
                Article
                yty088
                10.1093/ehjcr/yty088
                6177078
                2d18c618-2434-4d34-835f-4f6e0c464c7a
                © The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 14 March 2018
                : 6 July 2018
                Page count
                Pages: 5
                Categories
                Case Reports

                st-elevation myocardial infarction,cardiogenic shock,extracorporeal life support,extracorporeal membrane oxygenation,impella,left ventricular assist device,case report

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